Cirrhotic cardiomyopathy is independently associated with peritransplant acute kidney injury in biliary atresia: A hepato-cardio-renal link.

Abstract

Hepatorenal syndrome (HRS-AKI) confers significant morbidity and mortality in patients with cirrhosis. Cirrhotic cardiomyopathy (CCM), a prevalent comorbidity in adults with growing recognition in children, leads to hemodynamic perturbations that may compound the maladaptive physiology resulting in HRS-AKI. We aimed to explore a hepato-cardio-renal link in pediatric cirrhosis by examining peritransplant AKI, with a focus on CCM and Major Adverse Kidney Events at 28 days (MAKE28) in patients undergoing liver transplant (LT). This is a single-center, retrospective study of pediatric LT for biliary atresia (BA) from 2014 to 2020. Peri-LT AKI was defined as AKI within 7 days of LT. CCM was defined as left ventricular mass index to height of ≥95 g/m 2.7 , and/or relative wall thickness ≥0.42. Of 62 patients with BA (age 1.1 y [IQR: 0.8-2.4]), 29% had AKI, 61% had CCM, and 40% fulfilled MAKE28. Patients with AKI had higher blood product and vasoactive requirements, and lower ventilator-free days, compared with patients without AKI. The median length of stay was 133 (IQR: 54-121) versus 19.5 (IQR: 8.5-41) days for patients with AKI and without AKI, respectively ( p <0.001). CCM was more prevalent in those with peri-LT AKI (OR: 6.6, CI: 1.7-23, p =0.005). CCM remained significant after adjusting for age, markers of liver disease severity, and intraoperative events. Patients with BA face high morbidity peri-LT in the setting of prevalent AKI. The association between pediatric CCM and AKI suggests that cardiac dysfunction may be an independent risk factor for HRS-AKI. While studies are needed to further define the relationship between CCM and renal injury, pre-LT echocardiogram has the potential to facilitate timely identification and management of children at risk for HRS-AKI, and thereby promote renal recovery.